Why IUD Access in India Falls Short

Shilpi, 25, has two young daughters and wants to wait at least five years before she tries for a son. She uses birth control pills, which she gets alternately from her accredited social health activist (ASHA), a community health worker in her rural village in the North Indian state of Uttar Pradesh, or from the local community health center. But the ASHA doesn't always have the pills, the community health center is 6 miles away, and Shilpi doesn't have a car. Supply limits mean neither the ASHA nor the community health center are able to give her more than a month's supply of pills at a time, so at the end of every month, Shilpi tries the ASHA, then maybe the health center, then maybe each of them again, as she hustles to refill her contraception.

At the health center, Shilpi is meeting with a family welfare counselor to discuss other birth control options. The counselor tells Shilpi she could get an IUD, a long-acting and highly effective form of contraception that would remove the monthly scramble for more birth control pills and reliably prevent pregnancy — and it would be free. But Shilpi, like many Indian women, fears the IUD's side effects.

"I've heard that the IUCD can make you anemic," she says through a translator, using another acronym for the intrauterine contraceptive device. She has also heard it can make you weak, and cause gynecological problems and swelling in the body. "A small family is a happy family," Shilpi says, echoing a pro-family-planning phrase popularized by the Indian government. So for now, she's sticking with birth control pills.

Many Indian women reject the IUD, opting instead to depend on less reliable methods or no method at all; doctors report that many women would prefer to have abortions rather than have an IUD inserted. The problem, family planning groups say, is insufficient access to health-care providers, pervasive myths, and lack of education around contraception options. But there's a more concrete barrier too: the IUD itself.

The Indian women who rely on government hospitals for their health care typically have access to only one type of IUD: the copper T, which is free for low-income patients at government health centers. The copper T has been around since the 1970s and works via a relatively simple mechanism: The copper coiled around the T-shaped device causes the uterus and the fallopian tubes to produce sperm-killing fluid, bringing the risk of unintended pregnancy down to less than 1 percent. Insertion is relatively simple, and the copper IUD is such a crucial part of family planning that the World Health Organization has long included it on its list of essential medications.

The copper T is widely available in India, but still, most women don't use it. Aside from the copper T, lower-income women, often in rural areas or urban slums, have just one other option for reliable long-term birth control: sterilization. Fewer than 2 percent choose the IUD. More than a third get sterilized.

"There are some misconceptions [about the IUD]," says Reena Mittal, an ob-gyn at a hospital in Udaipur, in the North Indian state of Rajasthan. "They are not educated. They don't know anything about their own bodies. How can they know anything about contraception?"

"They think abortion is a way of contraception," she adds.

The misconceptions, Dr. Mittal says, include a pervasive fear that the IUD will perforate their uteruses, or that it will cause heavy bleeding, pain, infection, and discharge. Some of those fears are not totally unfounded, but statistically unlikely: Infections occur in less than 1 percent of IUD insertions, just 2 out of every 100 patients will expel the IUD, and uterine perforation is even less likely, occurring in 1 patient in 1,000.

But it's difficult to qualify some of the other concerns as "misconceptions." The copper T IUD can, in fact, cause cramping that ranges from uncomfortable to excruciating, sometimes for months, leading as many as 1 in 7 women in the U.S. to have their IUDs taken out within the first year of use. It can also cause long, heavy, severely painful menstrual periods — more than a simple inconvenience to women who do manual labor at home and in fields all day, and who are often not allowed in temples or, in the less-educated rural areas, even in their own kitchens if they're menstruating.

"It can be a problem, because basically if the bleeding continues for more than 15 days, in the rural areas, they are segregated aside, kept aside, they are not allowed to touch anything," Mittal says. "So they feel 15 days is too much for them."

The copper T IUD is also associated with anemia, which as many as three-quarters of Indian women in the eastern part of the country live with (and nearly half of women in western Indian states). Anemia, often caused in part by poor nutrition as many girls and women are routinely fed less than their brothers, fathers, and husbands, leads to about a fifth of the country's maternal deaths.

"If there were another method rather than vasectomy or tubal ligation, people might want that more," says Sarojini, an ASHA in a rural village called Bhadawal about two hours outside of the city of Kanpur in Uttar Pradesh. Sarojini gets up at 5:30 every morning, does her own household chores, and sets out for home visits with villagers by 9:30. She talks to them about all methods of contraception, including birth control pills, condoms, and injectables. But when she gets to sterilization and IUDs, women balk. "I struggle a lot to convince clients to get more permanent methods," she says, speaking through a translator.

ASHAs, in the state of Bihar, undergoing a Pathfinder family planning training.

Jill Filipovic

For decades, India has been trying to control its rapid population growth, with its numbers expanding so quickly that the country is set to surpass China as the world's most populous nation by 2022. Despite significant economic growth and an emerging middle class — not to mention a handful of citizens who have amassed astoundingly wealth —the country of more than a billion people still faces endemic poverty, poor health outcomes, high rates of maternal and infant mortality, limited sanitation, and stark economic inequality. Fighting the fundamental problem of too many people and too few resources, the government has focused on limiting and spacing births, making many forms of contraception free or very cheap in government hospitals, legalizing abortion, and leveraging the public health-care force of ASHAs, nurses, midwives, and doctors to encourage women to adopt family-planning methods.

That strategy, of which sterilization and copper T IUD access have been cornerstones, has improved health conditions for Indian women and decreased maternal mortality rates. But India's rates of maternal mortality have not declined quickly enough, and the country is almost certain to miss its Millennium Development Goal of reducing maternal mortality by 75 percent between 1990 and 2015. And since the 1960s, the concentration on reducing births has also led to a series of human rights abuses, with Indian men and women sterilized against their will or without their full consent.

What might help improve the landscape of birth control options for Indian women are the types of IUDs that poor women in India can't access. In the U.S., Mirena and Skyla IUDs are plastic alternatives that, unlike the copper T, release hormones. They don't typically come with the kind of cramps and bleeding that are features of the copper version, and they are helping to drive an uptick in American women's use of long-acting contraceptives — three-quarters of American women who use IUDs now use hormonal ones. But while the copper T is about $80 in the U.S., hormonal IUDs are closer to $400. A similar cost differential exists in India, making hormonal options available only for women who can afford both the device, and the private doctors who buy them and are able to insert them. Functionally, that means they're only available for moneyed, well-educated women in the big cities.

More long-term birth control options, some health workers say, could make a difference — if just a small one. But for now, the Indian health-care system remains largely in triage mode and always stretched for adequate funding. Adding more expensive birth control options that don't last as long — copper IUDs can stay in for 12 years, plastic ones between one and seven — is seen as an inefficient allocation of resources. Women's comfort, choices, and satisfaction with their contraceptive method remain low on the priority list.

And so reproductive health groups and local health workers work with what they've got. They report that they have better luck when they tell women what to expect — that uterine perforation is uncommon, but cramping may happen, and a warm compress or gentle pain medication can help. They also overwhelmingly say that long-acting or permanent contraception methods, even with their side effects, are far better and safer than repeated unwanted pregnancies. Every woman I spoke with about this issue, whether she had an IUD or a tubal ligation, reported being happy with her ultimate decision.

But women willing to talk to a reporter about birth control are not necessarily representative, and some human rights advocates worry that the Indian government's family-planning program may be coercive, especially given the fact that the country has a history of abusive, forced, and coerced sterilizations. In the 1960s and '70s, health workers were expected to meet official sterilization quotas in their districts; that led to millions of procedures on people who didn't necessarily qualify or consent. Those abusive practices, which often involved men undergoing vasectomies, are one reason Indian men today rarely consent to the procedure, leaving all the responsibility for family planning on women. Even though the Indian government no longer has sterilization and birth control quotas for health workers, just three years ago, Human Rights Watch reported that those targets still exist, especially for sterilization — they just aren't as formalized as they used to be.

The intensive focus on sterilization as the most effective family-planning method sometimes comes with a cost. Last year, 15 women died after ingesting tainted medicine at one of India's mass sterilization camps, leading observers around the world to ask why sterilizations were happening in camps in the first place. But within India, some were pointing to the country's history of sterilization quotas, and asking about a lesser-known but still-formalized provision to pay ASHAs according to how many women they convince to adopt the government's preferred methods for improving maternal health.

Reena, who has three children, learns about IUDs from Sarojini, but her mother-in-law, who has a say in this decision, is conflicted about birth control.

Jill Filipovic

One way the Indian government combats high maternal mortality rates is by incentivizing birth control and safe childbirth. ASHAs receive a small bonus for every woman they persuade to give birth in a health facility instead of at home, and whenever a client undergoes sterilization or gets an IUD. The rates vary, but ASHAs in Uttar Pradesh reported that they received about 600 rupees ($9) for a hospital birth and three antenatal checkups, and 150 rupees ($2.30) for a sterilization or IUD. In some districts, the women undergoing the procedures are also paid for delivering at a health center or getting sterilized. ASHAs don't get a similar bonus for distributing birth control pills, and because ASHAs are technically volunteers, they aren't paid a salary. The incentive structure was intended as a simple way of making sure ASHAs do their jobs, and ASHAs themselves say the incentives don't lead them to push women toward one contraception method over another — but some health advocates question whether that's true.

With the incentive structures in place for better or worse, women's rights NGOs are working hard to make sure women are given a range of choices and not pushed toward sterilizations. The nonprofit Pathfinder, for example, specifically trains family-planning counselors in what they call a "rights-based" framework, giving women as much information as possible and letting clients guide the process of choosing the right form of contraception for themselves. Other NGOs that focus on women's rights use similar models.

"Now the trend is changing to offer mixed method choices," Sarojini, the ASHA in Bhadawal village, says. She was also trained by Pathfinder. "The Indian government has seen the consequences of pushing sterilization."

The problem, though, is that there aren't actually a lot of options to choose from — sterilization and the copper IUD are the only long-term options. Aside from those, there are birth control pills, but not the smorgasbord of brands and hormonal combinations available to women in the U.S. and Europe, and there are injectables — but pills and injection contraceptives can be challenging for poor women, since those methods require regular contact with a health-care provider.

Another challenge reproductive health advocates face in many parts of the country is the fact that women, especially in the lower economic classes, do not make their reproductive choices alone, and the idea of reproductive freedom as a woman's right to choose what's best for herself is largely absent. If a woman wants an IUD inserted, but her husband or mother-in-law objects, it's a no-go.

"We try to convince her family," says Dr. Ashish Bajbai, a medical superintendent at the community health center in a rural area two hours outside of Kanpur. He explains that doctors work with ASHAs to leverage the support of local political leaders, village elders, and other local influencers. Usually, he says, that works. But if her family still says no to the IUD or sterilization, then at best she will get birth control pills, if she gets any contraception at all.

Newlyweds Reena and Vijay learn about contraception from Sarojini.

Jill Filipovic

In Bhadawal, Sarojini faces this exact problem. One of the women she meets with, Reena, has three children and is interested in contraception; her husband supports her, but mother-in-law, Bhagyawati, is wavering. Bhagyawati wants Reena to have more children, especially a boy, and Bhagyawati is increasingly influenced by her sister-in-law, Kishori Devi (Bhagyawati and Devi are married to brothers and live in a multi-family home with Reena, Reena's husband, and their children). Devi opposes birth control. In her day, she says, no one used contraception — and that was important to keep the Hindu population high in a mixed-religion neighborhood.

"The Muslims, they reproduce so much, isn't it?" Devi says. "Hindus all got [sterilized], but the Muslims don't."

Muslims, she says, "All have jobs, they are wealthy. And we're living hand-to-mouth." The fundamental problem, she says, is that Hindus keep their families small, at the Indian government's encouragement.

All of that leaves Reena in limbo. She didn't get an IUD inserted after giving birth, a common postpartum procedure, but when she stops breastfeeding her youngest in a few months, she would like to get one — if everyone agrees to it.

For women like Reena, the only long-term option, other than tubal ligation and the copper T IUD, is for their husbands to undergo vasectomies. Even though vasectomies are highly effective, come with fewer risks than
tubal ligations and can be done in a 10-minute outpatient procedure, pervasive myths combined with coercive and forced procedures in previous decades mean that just 1 percent of Indian men undergo them.

"Patients fear having the operation," says Hameeda Kaushar, a Family Welfare Counselor who serves almost 1,000 clients in another village outside of Kanpur. "Men worry about their desire and that their physical strength will decrease." Vasectomies, too, are not error-proof, and many women fear that if they get pregnant after their husband has undergone a sterilization procedure, their families and communities will assume they've been unfaithful, and they'll be ostracized.

The good news, health workers say, is that the reproductive rights landscape is changing, albeit slowly. In Bhadawal, the same village where Reena awaits the opinion of her mother-in-law, another Reena has just moved in. She's 19, slender, making eye contact only fleetingly. She sits next to her husband of four months, Vijay, who's 22. Reena grew up in a village 25 miles away; her marriage to Vijay was arranged, as are most marriages here; he has a ninth-grade education, she a third. Despite that they met for the first time on their wedding day, they're gently affectionate, laughing and teasing each other, he putting a protective hand on hers when she turns pink because I ask her about sex. Before marrying Vijay, Reena had never heard about contraception and didn't know much about sex. But Vijay was raised in this village, and Sarojini, the ASHA, visited his school to give the kids some basic information about puberty. When he and Reena got married, Vijay thought it was important to wait a bit to have kids. "We wanted to spend some time together, since the environment is new for her," Vijay says through a translator. So when Sarojini came around to visit their home after the wedding, they asked her some questions. Sarojini told them about contraception, and for now, they're using condoms.

Vijay and Reena do want children in the near future, and if they have a girl, they want her to study and have a job. Two kids, they think, is the ideal — "more will hinder our progress," says Vijay. Luckily for Reena, Vijay's mother, who lives with them and has seven children of her own, agrees.

"When I was younger, there were not these services," she says through a translator. "If I had them, I wouldn't have had as many kids. I sacrificed all my needs and desires to have my kids. I didn't care about myself."

She says she's happy to see her son and daughter-in-law take a different path. Vijay and Reena don't know yet if they'll use the IUD, sterilization, or something else when they're finished having children, but Reena says she doubts she'll face any issues making her own decisions. "Society is changing," she says.

Maybe, in a few years, their birth control options will have caught up.

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